|Year : 2013 | Volume
| Issue : 4 | Page : 159-162
Trocarless laparoscopic pyloromyotomy with conventional instruments: Our experience
Sandesh V Parelkar, Pooja V Multani, Beejal V Sanghvi, Shishira R Shetty, Hemangi R Athawale, Satish P Kapadnis, Dinesh D Mundada, Sanjay N Oak
Department of Pediatric Surgery, KEM Hospital, Parel, Mumbai, India
|Date of Submission||24-Nov-2012|
|Date of Acceptance||22-Jan-2013|
|Date of Web Publication||27-Sep-2013|
Pooja V Multani
Department of Pediatric Surgery, Old Building, King Edward Memorial Hospital, Parel - 400012, Mumbai
Source of Support: None, Conflict of Interest: None
Background: The incidence of hypertrophic pyloric stenosis is approximately 1-3 per 1,000 live births. Hypertrophic pyloric stenosis is seen more often in males, with a male-to female ratio of 4:1. Laparoscopic pyloromyotomy is becoming increasingly popular as the standard treatment for hypertrophic pyloric stenosis. Materials and Methods: We describe our initial experience with laparoscopic pyloromyotomy in 16 infants using conventional laparoscopic instruments. Laparoscopic pyloromyotomy was performed through 5-mm umbilical port with 5mm 30 endoscope. Two 3-mm working instruments were inserted directly into the abdomen via separate lateral incisions. Results: All patients were prospectively evaluated. The procedure was performed in 16 infants with a mean age of 36 days and mean weight of 3.1 kg. All procedures, except two, were completed laparoscopically with standard instruments. Average operating time was 28 mins, and average postoperative length of stay was 2.8 days. There were no major intraoperative and postoperative complications. Conclusion: Laparoscopic pyloromyotomy can be safely performed by using standard conventional laparoscopic trocarless instruments.
Keywords: Conventional instruments, laparoscopic, pyloromyotomy, trocarless
|How to cite this article:|
Parelkar SV, Multani PV, Sanghvi BV, Shetty SR, Athawale HR, Kapadnis SP, Mundada DD, Oak SN. Trocarless laparoscopic pyloromyotomy with conventional instruments: Our experience. J Min Access Surg 2013;9:159-62
|How to cite this URL:|
Parelkar SV, Multani PV, Sanghvi BV, Shetty SR, Athawale HR, Kapadnis SP, Mundada DD, Oak SN. Trocarless laparoscopic pyloromyotomy with conventional instruments: Our experience. J Min Access Surg [serial online] 2013 [cited 2019 May 23];9:159-62. Available from: http://www.journalofmas.com/text.asp?2013/9/4/159/118831
| ¤ Introduction|| |
Hypertrophic pyloric stenosis (HPS) is a common problem encountered during infancy. The Ramstedt pyloromyotomy, developed in 1911, remains the standard treatment for this condition. Laparoscopic pyloromyotomy was introduced in 1991 by Alain and Grousseau.  However, the risk of duodenal injury has deterred many surgeons from using this method.  Since then, studies have shown better cosmesis and similar complication rates compared with open pyloromyotomy. , The aim of this study was to assess the safety and potential benefits of laparoscopic pyloromyotomy for infantile HPS in our hospital using conventional trocarless working instruments. This report describes the technique, challenges, and outcomes of our first 16 procedures.
| ¤ Materials and Methods|| |
Sixteen infants with diagnosis of HPS were treated over a period of 2 years from June 2010 to June 2012. All patients were evaluated with X-ray abdomen erect and ultrasonography. Diagnostic criteria used were clinical history of gastric vomiting, palpable olive and radiological evidence of pyloric length of more than 18mm and thickness of ≥4 mm. 
After admission and stabilization of electrolyte and acid base balance, the infants were posted for laparoscopic pyloromyotomy.
The infant was placed in the supine position. The surgeon, the assistant and the scrub nurse stood on left side of patient with the monitor at the head end towards the right side.
Patients received one dose of perioperative antibiotic before the procedure. A 5-mm port was inserted through a subumbilical incision. Pneumoperitoneum was created by open Hasson's technique. Insufflation of CO 2 was started at 0.1litre/min and increased till 1litre/min. Pressure was kept at around 6mmHg and was increased to maximum of 8 mmHg, if needed. Two 3 mm instruments were passed directly through the incisions, one in the right anterior axillary line slightly above the level of the umbilicus to grasp the stomach and the other in the epigastric region directly over the pylorus, used for incising and splitting of the pylorus. The stomach was pulled to the left to visualize the pylorus. Before each procedure, insulation of hook was checked by thorough inspection. An incision was made along the thickened pylorus from the stomach to the duodenum using 3 mm hook with monopolar coagulating current of 30 Watts [Figure 1]. The incision was deepened. At times, when the coagulating current was not enough, minimum cutting current was used to complete the incision (30 Watts). The 3 mm Maryland forceps were used to further split the hypertrophied muscle fibers until mucosa was visualized and spread [Figure 2]. A satisfactory pyloromyotomy was confirmed by ballooning out the intact mucosa and two separate independently moving pyloric edges. Mucosal perforation was excluded by insufflating the stomach with air via the nasogastric tube (NGT).
The 5 mm umbilical port site was closed with an absorbable suture and the skin of all wounds was reapproximated with an adhesive glue. NGT was removed on the table.
Feeds were gradually introduced after 12-18 hours. The infants were normally discharged the day after tolerating full feeds.
| ¤ Results|| |
Of the 16 cases 14 were males and two were females (Male: Female ratio 7:1) aged 3-12 weeks, (average 36 days). Weight at admission ranged from 2.3-3.5 kg (average 3.1 kg). Duration of illness ranged from 3 to 16 days (average 6 days).
The most common presentation was nonbilious vomiting. History of constipation was reported in 10 (62.5%) patients. Metabolic disturbances that needed correction were reported in 9 (56.25%) patients. Fourteen procedures were completed laparoscopically and two required conversion, one for suspected inadequate pyloromyotomy and another for mucosal perforation (conversion rate 6.25%). For inadequate pyloromyotomy, a complete pyloromyotomy was done by open technique. For mucosal perforation, which was at the gastric end of the pyloromyotomy, suturing was done by open technique. Both conversions occurred early in the series. No conversions occurred in the last 13 cases. For analysis of data of postoperative stay and time to tolerate full feeds, the infant with mucosal perforation was excluded. Average operating time was 28 mins (Range 18-38 mins). Average postoperative length of stay was 2.8 days (Range 1.8-3.6 days). All infants, except one with mucosal perforation, were started on full feeds after 12 hours and were discharged on full feeds. A mean of 27 hours (16-45 hours) was reported for the time to reach full feeds.
No postoperative complications were noted in any of the infants. One child had prolonged postoperative emesis and was managed conservatively. On followup, all infants had gained weight and were thriving well. All infants were reexamined 3 months after the surgery. It was difficult to identify the 3-mm-direct instrument insertion site in the abdominal wall [Figure 3].
| ¤ Discussion|| |
Surgical treatment of HPS was first described by Fredet and Lesne in 1907. The extramucosal pyloromyotomy was further refined by Ramstedt and it is considered to be one of the most consistently successful operations in the armamentarium of Pediatric Surgeons.  Despite the success, the procedure still has morbidity of up to 16%, mostly due to difficulty with postoperative emesis  or wound complications  Open approaches for HPS include median longitudinal incision, Robertson muscle splitting incision, Randolph's tranverse right upper quadrant incision and Tan and Bianchi's circumumbilical incision. AR Khan et al., observed 39 patients operated with circumumbilical incision and concluded that this technique results in increased operative time (28 minutes), more gastric manipulation (33% requiring extension of incision), higher wound infections (5.12%) and longer gastric atony (15.3%).
Video-assisted, minimally-invasive surgery is increasingly accepted in the pediatric population as more experience is gained and instruments become more refined. Laparoscopic pyloromyotomy was first described in 1991 by Alain et al.  Since then, several other groups have reported their experience with laparoscopic pyloromyotomy and also suggested technical improvements in the procedure. Rothenberg described his slice and pull technique in 1997 where he grasped the duodenum with laparoscopic Babcock's clamp and reported an average operating time of 13 minutes. All the reported techniques describe grasping and cutting from the duodenum toward the stomach. This increases the risk of tearing or perforating the duodenum, and has deterred some surgeons from attempting the laparoscopic technique. Bufo et al.,  described a safer technique in which the stomach rather than the duodenum was grasped and pyloromyotomy was completed with use of arthroscopy knife and specialized laparoscopic pyloric spreader and with a reported mean operating time of 29 ± 8.3 minutes and wound complications was reported in 4.3% patient. Harris and Cywes  presented a simple technique and used extended tip cautery and 2 reusable, laparoscopic pyloric spreaders. Daniel et al., used arthroscopy knife and pyloric spreader and reported average operating time of 24 ± 8 minutes and wound infections in 1.17% patients.
In 2004, a meta-analysis of reported studies by Hall  was unable to show a clear benefit of laparoscopic approach over the open technique. However, in a recent study conducted by, Sola and Neville  in 2009 which derived meta-analysis of data from five level 1 studies and one level 2 study, concluded that the laparoscopic approach yields a significantly reduced rate of total complications. Recently, advances in the laparoscopic technique have been reported by Salmai et al., by using 2.4 mm scope with 2mm direct instruments in 21 patients with average operating time of 13 minutes and use of high powered monopolar cautery (2.5 times higher than recommended by the electrocautery device manager). The author reported longer postoperative stay (87 hours) and also reduced illumination as problems with this technique.
We report the use of conventional laparoscopic trocarless working instruments and almost similar results as compared to various authors summarized in table above [Table 1] and [Table 2]. In fact, our most efficient laparoscopic time was only 18 mins.
Use of trocar-less instruments also reduces the incision size thus making it cosmetically appealing as compared to the conventional open pyloromyotomy. Retractable pyloromyotomy knives, laparoscopic pyloric spreader, an arthrotomy knife, myringotomy knife, indigenous knife placed in a laparoscopic needle holder have been used for performing laparoscopic pyloromyotomy by various authors. The use of cautery for deepening the incision has a risk of injury to the mucosa but with judicious use and proper pre-procedure checking of the intact insulation minimizes this risk. Hence the fear associated with the use of cautery is ought to be virtual and not real. The chance of injury to the mucosa was minimal. The hook could therefore be inserted liberally in the pylorus to divide the muscle at depth. Complete separation of the hypertrophied muscle could then easily be achieved using a 3 or 5 mm Maryland forceps.
Jain et al., reported the use of conventional instruments (n = 15). They compared conventional and special instruments (n = 12) and concluded similar results and lesser bleeding with the former.
No wound infections occurred in our laparoscopic group. Our technique of laparoscopic pyloromyotomy is a safe procedure that is as effective as the "gold standard'' conventional open Ramstedt's pyloromyotomy to treat HPS and results in a better cosmetic appearance than the open procedures.
| ¤ Conclusions|| |
Laparoscopic pyloromyotomy was performed safely and successfully using standard conventional laparoscopic trocarless instruments. Use of trocarless instruments is safe, effective and reduces incision size, improving cosmesis. We strongly recommend pre-procedure checking the insulation of these instruments.
We conclude that use of conventional trocarless working laparoscopic instruments for laparoscopic pyloromyotomy is better cosmetically and is comparable with other studies and conventional open pyloromyotomy.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]